Standardized trauma intake form with clinical decision support prompts improves care and reduces mortality for seriously injured patients in non-tertiary hospitals in Ghana: stepped-wedge cluster randomized trial.

Journal

The British journal of surgery

ISSN: 1365-2168

Titre abrégé: Br J Surg

Pays: England

ID NLM: 0372553

Informations de publication

Date de publication:
10 Oct 2023

Historique:

received: 25 04 2023

revised: 22 06 2023

accepted: 23 07 2023

pmc-release: 24 08 2024

pubmed: 24 8 2023

medline: 24 8 2023

entrez: 23 8 2023

Statut: ppublish

Résumé

The WHO Trauma Care Checklist improved key performance indicators (KPIs) of trauma care at tertiary hospitals. A standardized trauma intake form (TIF) with real-time clinical decision support prompts was developed by adapting the WHO Trauma Care Checklist for use in smaller low- and middle-income country hospitals, where care is delivered by non-specialized providers and without trauma teams. This study aimed to determine the effectiveness of the TIF for improving KPIs in initial trauma care and reducing mortality at non-tertiary hospitals in Ghana. A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models. Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009). The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients. NCT04547192 (http://www.clinicaltrials.gov).

Sections du résumé

BACKGROUND BACKGROUND

METHODS METHODS

A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models.

RESULTS RESULTS

Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009).

CONCLUSION CONCLUSIONS

The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients.

REGISTRATION NUMBER BACKGROUND

NCT04547192 (http://www.clinicaltrials.gov).

Identifiants

DOI: 10.1093/bjs/znad253 PMID: 37612450 PMC: PMC10564400

pubmed: 37612450

pii: 7249248

doi: 10.1093/bjs/znad253

pmc: PMC10564400

doi:

Banques de données

ClinicalTrials.gov

['NCT04547192']

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

Pagination

1473-1481

Subventions

Organisme : US National Institutes of Health

ID : TW011685

Informations de copyright

Références

N Engl J Med. 2009 Jan 29;360(5):491-9

pubmed: 19144931

Med Educ. 2017 Jan;51(1):31-39

pubmed: 27580703

J Trauma. 2000 Jan;48(1):119-24

pubmed: 10647576

J Inj Violence Res. 2021 Jan;13(1):5-12

pubmed: 32868497

Surg Open Sci. 2022 Apr 26;9:34-40

pubmed: 35620709

Contemp Clin Trials. 2015 Nov;45(Pt A):55-60

pubmed: 26247569

Ann Emerg Med. 2022 Oct;80(4):332-343

pubmed: 35752519

J Surg Res. 2020 Mar;247:280-286

pubmed: 31690530

World J Surg. 2022 Jun;46(6):1288-1299

pubmed: 35286419

Ann Surg. 2018 Aug;268(2):282-288

pubmed: 28806300

Injury. 2016 Jan;47(1):211-9

pubmed: 26492882

J Trauma. 1993 Oct;35(4):518-23

pubmed: 8411273

Emerg Med Australas. 2019 Aug;31(4):654-658

pubmed: 30690872

Stat Methods Med Res. 2021 Feb;30(2):612-639

pubmed: 32631142

World J Surg. 2017 Apr;41(4):954-962

pubmed: 27800590

S Afr Med J. 2019 Apr 29;109(5):299-305

pubmed: 31131794

JAMA. 2000 Apr 19;283(15):1990-4

pubmed: 10789667

JAMA Surg. 2016 Feb;151(2):164-71

pubmed: 26502036

Trauma Surg Acute Care Open. 2020 Jul 21;5(1):e000451

pubmed: 32724859

World J Emerg Surg. 2020 Aug 18;15(1):49

pubmed: 32811505

J Trauma Acute Care Surg. 2014 Nov;77(5):679-683

pubmed: 25494417

Emerg Med Clin North Am. 2018 Feb;36(1):203-218

pubmed: 29132578

Int J Epidemiol. 2020 Jun 1;49(3):979-995

pubmed: 32087011

Br J Anaesth. 2014 Aug;113(2):234-41

pubmed: 25038155

J Trauma. 1989 May;29(5):623-9

pubmed: 2657085